Overspecialized and undertrained? Patient diversity encountered by medical students during their internal medicine clerkship at a university hospital.

Melderis S, Gutowski JP, Harendza S - BMC Med Educ (2015)

Bottom Line:
The only subspecialty with no significant difference compared with on call was nephrology for diagnostic investigations.With respect to therapy, nephrology and infectious diseases showed no significant differences compared with on call.Shadowing the on call resident or shorter rotations could provide a more extended patient diversity.

Background: During the four-month internal medicine clerkship in their final year, undergraduate medical students are closely involved in patient care. Little is known about what constitutes their typical learning experiences with respect to patient diversity within the different subspecialties of internal medicine and during on call hours.

Methods: 25 final year medical students (16 female, 9 male) on their internal medicine clerkship participated in this observational single-center study. To detail the patient diversity encountered by medical students at a university hospital during their 16-week internal medicine clerkship, all participants self-reported their patient contacts in the different subspecialties and during on call hours on patient encounter cards. Patients' chief complaint, suspected main diagnosis, planned diagnostic investigations, and therapy in seven different internal medicine subspecialties and the on call medicine service were documented.

Results: 496 PECs were analysed in total. The greatest diversity of chief complaints (CC) and suspected main diagnoses (SMD) was observed in patients encountered on call, with the combined frequencies of the three most common CCs or SMDs accounting for only 23% and 25%, respectively. Combined, the three most commonly encountered CC/SMD accounted for high percentages (82%/63%), i.e. less diversity, in oncology and low percentages (37%/32%), i.e. high diversity, in nephrology. The percentage of all diagnostic investigations and therapies that were classified as "basic" differed between the subspecialties from 82%/94% (on call) to 37%/50% (pulmonology/oncology). The only subspecialty with no significant difference compared with on call was nephrology for diagnostic investigations. With respect to therapy, nephrology and infectious diseases showed no significant differences compared with on call.

Conclusions: Internal medicine clerkships at a university hospital provide students with a very limited patient diversity in most internal medicine subspecialties. Shadowing the on call resident or shorter rotations could provide a more extended patient diversity.

Mentions:
We found differences in both the diversity and nature of the chief complaints encountered within the different subspecialties. The greatest diversity was observed in the on call patients where the three most common chief complaints together accounted for only 23% of all on call PECs (Figure 2). On the wards, the three most common CCs ranged from 37 to 82%. The three most commonly encountered CCs were for the subspecialties: nephrology: fatigue and B symptoms, dyspnea, urogenital; endocrinology: admitted-with-diagnosis, fatigue and B symptoms, dyspnea/ musculoskeletal; infectious diseases: admitted-with-diagnosis, fatigue and B symptoms, fever; gastroenterology: admitted-with-diagnosis, abdominal pain, abnormal liver function tests; oncology/hematology: fatigue and B symptoms, admitted-with-diagnosis, musculoskeletal; pulmonology: dyspnea, cough, fatigue and B symptoms; cardiology: dyspnea, chest pain, admitted-with-diagnosis. The most commonly encountered complaint on call was abdominal pain.Figure 2

Mentions:
We found differences in both the diversity and nature of the chief complaints encountered within the different subspecialties. The greatest diversity was observed in the on call patients where the three most common chief complaints together accounted for only 23% of all on call PECs (Figure 2). On the wards, the three most common CCs ranged from 37 to 82%. The three most commonly encountered CCs were for the subspecialties: nephrology: fatigue and B symptoms, dyspnea, urogenital; endocrinology: admitted-with-diagnosis, fatigue and B symptoms, dyspnea/ musculoskeletal; infectious diseases: admitted-with-diagnosis, fatigue and B symptoms, fever; gastroenterology: admitted-with-diagnosis, abdominal pain, abnormal liver function tests; oncology/hematology: fatigue and B symptoms, admitted-with-diagnosis, musculoskeletal; pulmonology: dyspnea, cough, fatigue and B symptoms; cardiology: dyspnea, chest pain, admitted-with-diagnosis. The most commonly encountered complaint on call was abdominal pain.Figure 2

Bottom Line:
The only subspecialty with no significant difference compared with on call was nephrology for diagnostic investigations.With respect to therapy, nephrology and infectious diseases showed no significant differences compared with on call.Shadowing the on call resident or shorter rotations could provide a more extended patient diversity.

Background: During the four-month internal medicine clerkship in their final year, undergraduate medical students are closely involved in patient care. Little is known about what constitutes their typical learning experiences with respect to patient diversity within the different subspecialties of internal medicine and during on call hours.

Methods: 25 final year medical students (16 female, 9 male) on their internal medicine clerkship participated in this observational single-center study. To detail the patient diversity encountered by medical students at a university hospital during their 16-week internal medicine clerkship, all participants self-reported their patient contacts in the different subspecialties and during on call hours on patient encounter cards. Patients' chief complaint, suspected main diagnosis, planned diagnostic investigations, and therapy in seven different internal medicine subspecialties and the on call medicine service were documented.

Results: 496 PECs were analysed in total. The greatest diversity of chief complaints (CC) and suspected main diagnoses (SMD) was observed in patients encountered on call, with the combined frequencies of the three most common CCs or SMDs accounting for only 23% and 25%, respectively. Combined, the three most commonly encountered CC/SMD accounted for high percentages (82%/63%), i.e. less diversity, in oncology and low percentages (37%/32%), i.e. high diversity, in nephrology. The percentage of all diagnostic investigations and therapies that were classified as "basic" differed between the subspecialties from 82%/94% (on call) to 37%/50% (pulmonology/oncology). The only subspecialty with no significant difference compared with on call was nephrology for diagnostic investigations. With respect to therapy, nephrology and infectious diseases showed no significant differences compared with on call.

Conclusions: Internal medicine clerkships at a university hospital provide students with a very limited patient diversity in most internal medicine subspecialties. Shadowing the on call resident or shorter rotations could provide a more extended patient diversity.